True Identity by Immunohistochemistry

● Context.—‘‘Undifferentiated tumor’’ refers to a heterogeneous group of neoplasms with little or no evidence of differentiation on routine light microscopic morphology. Objective.—To identify the true identity of undifferentiated tumors by immunohistochemical analysis. Data Sources.—Review of the pertinent literature and the authors’ experience. Conclusions.—For treatment and prognostic evaluation, it is crucial to delineate whether an undifferentiated neoplasm is epithelial, mesenchymal, melanocytic, or hematopoietic in nature. Application of a screening panel to demonstrate the expression of markers of major lineages is fundamental for determination of the broad category of neoplasia. Because poorly differentiated carcinomas and in particular sarcomatoid carcinomas are known to be heterogeneous in their antigen expression, several epithelial markers in combination may be required to establish the carcinomatous nature of tumor. A diagnostic misinterpretation as a consequence of occasional aberrant or unexpected antigen expression is best avoided by using a broad panel that includes both antibodies that are anticipated to be positive and those that are expected to be negative. In this treatise, the immunohistochemical dissection of undifferentiated tumors on the basis of their morphologic features is outlined, supplemented with algorithmic immunohistochemical analysis for each morphologic category of small round cell tumors, carcinomatous tumors, sarcomatous (or sarcoma-like) tumors, and tumors with histologically overlapping features, including hematolymphoid malignancies, melanoma, and sarcomas with epithelioid appearance. The utility of several organor tissue-specific markers in the context of undifferentiated tumors is reviewed. (Arch Pathol Lab Med. 2008;132:326–348)